An altered balance of plasma arginine metabolites is associated with increased thickness of the coronary intima-media complex in the adjacent to the culprit segment of an infarct-related artery

Background

The biomarkers of atherosclerosis remain insufficiently understood.

Purpose

We sought to investigate whether an altered balance of arginine metabolites in patients following myocardial infarction (MI) is associated with remodeling of the adjacent to the culprit segments of an infarct-related artery (IRA) and with clinical outcomes.

Methods

Arginine and its metabolites including ornithine, citrulline, proline and asymmetric dimethylarginine were measured using liquid chromatography and tandem mass spectrometry in 85 consecutive ST-segment elevation MI patients upon admission and at 6-month follow-up and were compared with morphology of the adjacent to the culprit proximal and distal 10-mm segments of IRA assessed with optical coherence tomography. A composite ischemic event was defined as death, recurrent MI, stroke, or unplanned percutaneous coronary intervention.

Results

The ratios of citrulline/ornithine and citrulline/arginine decreased 5.22 and 2.20 times (both P<0.001) respectively, while the ornithine/arginine index (I_O/A) increased 2.96 times (P<0.001) following ischemia compared with stable follow-up, indicating the enhanced arginase activity over nitric oxide synthase (NOS) in acute phase of STEMI. Follow-up I_O/A correlated with the mean intima-media (R=0.34, P=0.003, Figure 1A) and intima (R=0.30, P=0.008) diameter of an adjacent to the culprit IRA segment. By multivariate analysis, apart from male gender (P<0.001) and diabetes mellitus (P=0.02), a higher follow-up I_O/A was associated with the larger mean intima-media diameter of an adjacent to the culprit IRA segments (coefficient 0.218, 95% confidence interval 0.040–0.397, P=0.017, per 0.01). Within the median follow-up of 25 (19–35) months, ischemic composite endpoint was found in 13 (15.3%) patients. The follow-up I_O/A reached the area under the ROC curve of 0.78 (95% confidence interval 0.66–0.91, P=0.005) for prediction of composite ischemic endpoint with a cut-off value of ≥0.57, and a sensitivity of 72.3% and specificity of 80.0% (Figure !B).

Conclusions

Our findings provide arguments that during the acute phase of MI, arginine metabolism is shifted from NOS towards arginase, as compared to 6-month stable conditions. Simultaneously, the enhanced residual arginase activity over NOS in chronic phase was correlated with a higher thickness of intima or intima-media in the adjacent to the culprit segment within the IRA, and was also associated with unfavorable clinical outcomes.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Grant of the National Science Center of Poland (Number 2016/21/B/NZ5/01378 to J.Z.)

Use of statins in cancer patients following acute myocardial infarction and its impact on long-term clinical outcomes

Background

Statin use and its impact on long-term clinical outcomes in cancer patients following acute myocardial infarction (MI) remains insufficiently elucidated.

Purpose

We sought to analyze the prevalence of statins use in MI patients with cancer hospitalized in a tertiary cardio-oncology center and its influence on long-term mortality.

Methods

Of the 1,011 consecutive acute MI patients hospitalized between 2012 and 2017, cancer was found in 134 (13.3%) subjects including newly diagnosed cancer in 24 of them. All patients underwent coronary angiography. Within a median follow-up of 69.2 (37.8–79.9) months, a mortality rate, and its determinants were analyzed.

Results

Compared with non-cancer population, MI patients with cancer were older (73 [66–79] versus 68 [60–78] years, P<0.001), had lower hemoglobin level (12.8 [11.2–14.0] vs 13.8 [12.8–15.0], P<0.001), lower total cholesterol (4.1 [3.4–4.8] vs 4.4 [3.6–5.3], P=0.006) and lower HDL cholesterol (1.1 [0.9–1.4] vs 1.2 [1.0–1.6], P<0.001), without significant differences in LDL cholesterol (2.5 [1.9–3.1] vs 2.6 [1.7–3.4], P=0.70). Statins were prescribed less frequently in MI patients with cancer as compared with non-cancer MI population (80.5% versus 92.1%, P<0.001). Atorvastatin was the most frequent statin in both cancer and non-cancer groups (68.4% versus 75.1%, P=0.13). In cancer group simvastatin was more frequently (16.7% versus 5.9%, P<0.001) while rosuvastatin was less frequently (8.8% versus 18.9%, P=0.007) prescribed than in non-cancer patients. The independent determinants of no use of statins were anemia (hazard ratio [HR] 2.3, 95% confidence interval [95% CI] 1.3–4.2, P=0.006), no coronary artery stenosis >50% (HR 5.0, 95% CI 2.5–10.1, P<0.001) and cancer (HR 1.9, 95% CI 1.01–3.7, P=0.049) but not LDL cholesterol. The mortality rates were significantly higher in MI patients not treated with statins, both in non-cancer population (29.5%/year versus 6.7%/year, P<0.001) as well as in cancer group (53.9%/year versus 24.9%/year, P<0.05) as compared to those treated with statins (Figure 1). No statin use (HR 2.3, 95% CI 1.8–3.0, P<0.001), an active cancer (HR 2.3, 95% CI 1.8–3.0, P<0.001), patient's age (HR 2.3, 95% CI 1.8–2.9, P<0.001, per year) and anemia (HR 1.7, 95% CI 1.4–2.1, P<0.001) independently increased long-term mortality while no coronary artery stenosis >50% (HR 0.65, 95% CI 0.44–0.96, P=0.03) and better left ventricular ejection fraction (HR 0.97, 95% CI 0.96–0.98, P<0.001, per 1%) improved long-term survival.

Conclusions

An active cancer, anemia and lack of significant coronary lesions were associated with no use of statins in patients following MI. By multivariable approach both no statins use in MI patients independently on an active malignancy were associated with unfavorable long-term outcomes.

Funding Acknowledgement

Type of funding sources: None.

The determinants and significance of intraluminal stent protrusion in patients with acute myocardial infarction

Background

The mchanisms leading to intraluminal stent protrusion in patients following primary coronary angioplasty for ST-elevation myocardial infarction (STEMI) are not fully elucidated.

Purpose

We sought to investigate composition of stent protrusion, its systemic and local determinants as well as its consequences for epicardial blood flow restoration in STEMI patients.

Methods

We enrolled 85 STEMI patients with median age 61 (interquartile range 54–69) years. In all patients optical coherence tomography of an infarct-related artery was performed first following epicardial blood flow restoration after aspiration thrombectomy and second after final stent deployment. On admission, besides standard laboratory investigations we measured calibrated automated thrombogram parameters including time to start clotting, time to peak thrombin generation, peak thrombin generation and endogenous thrombin potential as well as ex vivo measured fibrin clot permeability reflecting fibrin pore size and fibrin clot lysis time.

Results

A median volume of stent protrusion was 13.4 (8.5–25.4) mm3 while atherothrombotic burden defined as a ratio of free intraluminal thrombus and tissue protrusion divided by stent volume was 6 (3.9–7.5)%. The main component of stent protrusion was lipid tissue in 32 (37.6%), fibrous tissue in 27 (31.8%) and thrombus in 26 (30.6%) patients. A volume of stent protrusion was correlated with total stent volume (R=0.79, P<0.001) and the length of lipid reach pool in the naïve coronary vessel intima (R=0.31, P=0.007) whereas atherothrombotic burden was correlated with residual thrombus volume before stent implantation (R=0.34, P=0.003), arcus of maximal lipid reach pool in the naïve coronary vessel intima (R=0.25, P=0.03) and stent area (R=0.26, P=0.02). The residual thrombus volume after aspiration thrombectomy was correlated with clot permeability (R=0.024, P=0.04) and inversely correlated with time to peak thrombin generation (R=−0.23, P=0.04). A temporary deterioration of epicardial blood flow of at least 1 point in Thrombolysis in Myocardial Infarction scale following stent implantation detected in 20 (23.5%) patients was associated with shorter lag time (3.0 [2.7–3.3] vs. 3.3 [3.0–4.0] min, P=0.015), shorter time to peak thrombin generation (5.7 [5.3–6.1] vs. 6.3 [5.7–7.1] min, P=0.026) and more frequent presence of lipid-rich stent protrusion (65 vs. 29%, P=0.007) as compared to the patients without slow-flow phenomenon after stent deployment.

Conclusions

The total volume of stent protrusion is correlated with local determinants including stent size and lipid content in the naïve coronary artery intima. After adjustment for stent volume, atherothrombotic burden is additionaly affected by residual thrombus volume after aspiration thrombectomy. However, patients with faster thrombin formation and lipid-rich stent protrusion are more prone to slow-flow phenomenon following stent implantation.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Science Center of Poland

Coronary slow-flow phenomenon in takotsubo syndrome: the prevalence, clinical determinants and long-term prognostic impact

Background

Previous studies demonstrated that patients with takotsubo syndrome (TTS) may present with coronary slow-flow (CSF) at coronary angiography performed in the acute phase [1]. However, the exact clinical relevance and its long-term prognostic impact have not been established yet. In the only recently published study Montone et al. proved that TTS patients with CSF were characterized by a worse clinical presentation with higher rate of intrahospital complications and poor long-term clinical outcome [2].

Purpose

We sought to investigate the prevalence of CSF in TTS patients, its determinants and long-term prognostic impact.

Methods

Among 7771 myocardial infarction patients hospitalized in our center in 2012–2019 years, we identified 82 (1.1%) TTS patients with performed coronary angiography (Figure 1A). The coronary flow was assessed quantitatively with TIMI Frame Count (TFC), whereas myocardial perfusion with TIMI myocardial perfusion grade (TMPG). The clinical and angiographic characterstics of 67 TTS patients complying with MINOCA definition were compared with representative 50 non-TTS MINOCA (Figure 1A).

Results

CSF (TIMI 2) was identified in 33 (40.2%) TTS patients. CSF-TTS patients were characterized with higher TFC and worse TMPG in each analyzed coronary vessel (Figure 1B). CSF was observed in LAD artery in each patient, in 78.8% in LCx and in 33.3% in RCA, respectively. In CSF-TTS lower values of LVEF on admission (33.5 (25–40) vs 40 (35–45)%, P=0.019) as well as more frequent midventricular TTS (27.3 vs 8.2%, P=0.020), nearly normal coronary arteries (<30% stenosis) (75.8 vs 49.0%, P=0.015) and coexistence of both physical and emotional triggers (9.1 vs 0%, P=0.032) were noted. Moreover, CSF was observed significantly more frequent than in non-TTS MINOCA (44.8 vs 10.0%, P<0.001) with different distribution in particular vessels (P<0.001). In median 55 months of long-term observation higher all-cause mortality was stated in CSF-TTS (30.3 vs 10.2%, P=0.024) (Figure 1C) without difference between TTS and non-TTS MINOCA (P=0.42) (Figure 1D). By Cox proportional hazards model the CSF was identified as an independent predictor of long-term mortality (P<0.001).

Conclusions

As has been shown high proportion of TTS patients were characterized with remarkably marked myocardial perfusion abnormalities, especially in the left coronary vessels, which were associated with unfavorable long-term prognosis. Our study is the first presenting the direct angiographic, clinical and prognostic comparison of TTS MINOCA and non-TTS MINOCA patients.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Temporal changes in the implementation of secondary prevention of coronary artery disease in every day practice

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

-

Introduction

Patients with coronary artery disease (CAD) are at high risk of recurrent cardiovascular events and control of their risk factors is crucial.

Objectives

Comparison of risk factors control in patients with CAD in 2016–2017 and 2011–2013.

Patients and methods

Five hospitals with cardiology departments serving the city and surrounding districts participated in the study. Consecutive patients hospitalized due to an acute coronary syndrome or a myocardial revascularization procedure were interviewed 6–18 months after hospitalization. The surveys were carried out in 2011–2013 and 2016–2017.

Results

We examined 616 patients in 2011–2013 and 388 in 2016–2017 (mean age: 64.7 ± 8.8 vs. 66.4 ± 8.4, P <0.01). After adjusting for covariates the proportion of patients with high blood pressure decreased by 8.9% (95% confidence intervals: -2.1% – -15.6%) and proportion of patients with high LDL cholesterol decreased by 9.5% (-2.2% – -16.7%) in 2016/2017 compared to 2011/2013, whereas the proportion of smoking patients (-0.2% [-6.0% – 5.5%]) and those with high glucose level (3.9% [-2.2% - 10.0%]) and with body mass index ≥25 kg/m2 (3.8% [-3.9% – 11.6%]) did not change significantly. The proportion of patients prescribed antiplatelets (6.5% [2.6% - 10.3%]), β-blockers (7.4% [2.2% - 12.6%]), angiotensin converting enzyme inhibitors or sartans (8.6% [2.9% – 14.3%]), calcium antagonists (8.1% [1.3 – 15.0]) and anticoagulants (5.5% [0.7% - 10.2%]) increased significantly.

Conclusions

In CAD patients, there was an increase of the proportion of patients with cardiovascular drugs prescribed and a slight improvement in the control of blood pressure and LDL cholesterol between 2011–2013 and 2016–2017. However, no significant changes were found for the other main risk factors.

Patients who do not reach treatment goal Survey Smoking, % BP not at goal, %a BP ≥140/90 mmHg, % LDL cholesterol ≥1.8 mmol/l, % HbA1c ≥7.0%b, % Fasting glucose ≥7.0 mmol/l, % BMI≥25 kg/m2, % BMI≥30 kg/m2, % 2011-2013 19.0 50.3 43.0 71.9 14.1 15.9 81.2 33.8 2016-2017 16.2 40.7 39.2 60.3 14.9 20.2 83.4 38.3 P value 0.26 <0.01 0.24 <0.001 0.76 0.09 0.37 0.14 Differences adjusted for age, sex, index diagnosis, duration of education, professional activity (95% confidence intervals) 2016-2017 vs 2011-2013 -0.2(-6.0 - 5.5) -8.9(-15.6 - -2.1) -6.7(-14.3 - 1.0) -9.5(-16.7 - -2.2) 2.0(-3.4 - 7.4) 3.9(-2.2 - 10.0) 3.8(-3.9 - 11.6) 1.6 (-5.8 - 9.0) Abbreviations BMI, body mass index; BP, blood pressure; LDL, low-density lipoprotein a BP goal of <140/90mmHg (<130/80 mmHg in diabetics) in 2011–2013 and <140/90 mmHg (<140/85 mmHg in diabetics) in 2016–2017 b available for 362 patients in 2011-2013 and 383 patients in 2016-2017

Spider silk nerve graft promotes axonal regeneration on long distance nerve defect in a sheep model

Peripheral nerve injuries with substantial tissue loss require autologous nerve transplantation or alternatively reconstruction with nerve conduits. Axonal elongation after nerve transection is about 1 mm/day. The precise time course of axonal regeneration on an ultrastructural level in nerve gap repair using either autologous or artificial implants has not been described. As peripheral nerve regeneration is a highly time critical process due to deterioration of the neuromuscular junction, this in vivo examination in a large animal model was performed in order to investigate axonal elongation rates and spider silk material degradation in a narrowly delimited time series (20, 30, 40, 50, 90, 120, 150 and 180 days) by using a novel spider silk based artificial nerve graft as a critical prerequisite for clinical translation. Autologous nerves or artificial nerve conduits based on spider silk of the spider species Trichonephila edulis were transplanted in a 6.0 cm nerve defect model in the black headed mutton. At each of the post-implant time point, electrophysiology recordings were performed to assess functional reinnervation of axonal fibers into the implants. Samples were analyzed by histology and immunofluorescence in order to verify the timeline of axonal regeneration including axonal regeneration rates of the spider silk implant and the autologous transplant groups. Spider silk was degraded within 3 month by a light immune response mainly mediated by Langhans Giant cells. In conjunction with behavioral analysis and electrophysiological measurements, the results indicate that the spider silk nerve implant supported an axonal regeneration comparable to an autologous nerve graft which is the current gold standard in nerve repair surgery. These findings indicate that a biomaterial based spider silk nerve conduit is as effective as autologous nerve implants and may be an important approach for long nerve defects.

Dementia screening in elderly high-risk patients following heart failure decompensation may predict unfavorable long-term clinical outcomes

Background

Recently heart failure (HF) has been found to be a new dementia risk factor, nevertheless their relations in patients following HF decompensation remain unknown.

Purpose

We sought to investigate whether a screening diagnosis for dementia (SDD) in this high-risk population may predict unfavorable long-term clinical outcomes.

Methods

142 patients following HF decompensation requiring hospitalization were enrolled. Within a median time of 55 months all patients were screened for dementia with ALFI-MMSE scale whereas their compliance was assessed with the Morisky Medication Adherence Scale. Any incidents of myocardial infarction, coronary revascularization, stroke or transient ischemic attack (TIA), revascularization, HF hospitalization and bleedings during follow-up were collected.

Results

SDD was established in 37 patients (26%) based on the result of an ALFI-MMSE score of <17 points. By multivariate analysis the lower results of the ALFI-MMSE score were associated with a history of stroke/TIA (β=−0.29, P<0.001), peripheral arterial disease (PAD) (β=−0.20, P=0.011) and lower glomerular filtration rate (β=0.24, P=0.009). During the follow-up, patients with SDD were more often rehospitalized following HF decompensation (48.7% vs 28.6%, P=0.014) than patients without SDD, despite a similar level of compliance (P=0.25). Irrespective of stroke/TIA history, SDD independently increased the risk of rehospitalization due to HF decompensation (HR 2.22, 95% CI 1.23–4.01, P=0.007).

Conclusions

As shown for the first time in literature patients following decompensated HF, a history of stroke/TIA, PAD and impaired renal function independently influenced SDD. In this high-risk population, SDD was not associated with patients' compliance but irrespective of the stroke/TIA history it increased the risk of recurrent HF hospitalization.

The survival free of rehospitalization

Funding Acknowledgement

Type of funding source: None

The artificial intelligence system in prediction of the prevalence of acute coronary syndromes based on weather conditions

Background

It was shown that different individual weather conditions are associated with the incidence of acute coronary syndromes (ACS). Despite this, the prediction of the number of ACS depending on the weather conditions in the given place and time is not effective to date.

Purpose

We sought to investigate whether the artificial intelligence system might be useful in prediction of the prevalence of ACS based on weather conditions.

Methods

In this study, data of 159307 consecutive patients obtained from National Health Service registry, hospitalized due to ACS in Lesser Poland Province (province area of 15008 km2, population of 3.4 M in 2014) between 2008 and 2018 have been compared with meteorological conditions collected in the Institute of Meteorology and Water Management from five weather stations scattered across Lesser Poland Province. Because of small sample size in three of them, only data from two stations (Krakow-Balice, n=75565, Tarnow, n=30079) were used for further analysis. In four separate seasons, the number of ACS events in each day was compared with meteorological conditions on a given day and six days before. We analysed weather conditions such as: wind 10 metres above ground (W_10), temperature (T), dew point temperature (T_dp), relative humidity 2 metres above the ground (Hum_2), atmospheric pressure reduced to mean sea level (Pres), atmospheric precipitation (Prec), and 3 hours atmospheric pressure changes (Pres_3h). For all parameters extreme (maximum – max, minimum – min) values and ranges of these parameters in each day were analysed. All data were used in a system based on machine learning (Random Forest), which allowed to create a model that predicted the incidence of ACS and to determine importance of each inputted weather parameter in this prediction.

Results

All weather parameters were divided into machine learning data (70%) and test data (30%) to verify functioning of the model. The correlation between real number of ACS and predicted number of ACS for two meteorological stations for spring ranges from 0.69 to 0.71 with confidence intervals (CI) of 0.63–0.77, for summer the correlation was 0.66–0.75 with CI of 0.59–79, for autumn 0.69–0.74 with CI of 0.63–0.79 and for winter 0.69–0.72 with CI 0.63–0.77 (P<0.0001 for each prediction, example of prediction in the Figure 1A). Among all analysed meteorological parameters the most important in the machine learning were range of relative humidity, range of dew point temperature and maximal relative humidity (Figure 1B).

Conclusions

Artificial intelligence system seems to be useful in predicting the prevalence of ACS with model based on weather conditions.

Figure 1. ACS prediction for summer in Krakow

Funding Acknowledgement

Type of funding source: None

Over-representation of myocardial infarction with nonobstructive coronary arteries in oncological patients. The prevalence, clinical characteristics and long-term mortality

Introduction

According to the current guidelines, myocardial infarction with nonobstructive coronary arteries (MINOCA) is defined by general criteria of myocardial infarction (MI) with no hemodynamically significant lesions in coronary arteries (<50%). As shown in large MI registers, MINOCA is diagnosed in 1–13% of patients. The potential etiology of MINOCA is an intensively studied issue. To date, a number of potential mechanisms have been proposed. In our opinion, hypercoagulable states may be indicated as a direct trigger for such a sequence of events. Based on our previously published study, we found the presence of inherited thrombophilia in over 23.8% of MINOCA patients

Purpose

We suspect that oncological patients, the group with well-known prothrombotic state, are predisposed to MINOCA and have different clinical characteristics and long-term prognosis.

Methods

We analyzed a group of 1011 consecutive patients with MI who underwent coronary angiography in the years 2012–2017. A group of 134 patients with active cancer (13.3%) was separated. Working diagnosis of MINOCA was performed in accordance with current guidelines.

Results

MINOCA diagnosis was stated in 21 oncological patients (15.7%) and 51 others (5.8%) (P<0.001). Cancer patients were characterized by a higher incidence of anemia (47.6 vs 21.6%, P=0.027), lower hemoglobin levels (12.9 vs 14.1 g/dl, P=0.048) and higher troponin values (0.306 vs 0.076 ng/ml, P=0.003). Based on echocardiographic measurements, more frequent occurrence of takotsubo cardiomyopathy (19.1 vs 2.0%, P=0.010), higher values of right ventricular systolic pressure (44.5 vs 31.5 mmHg, P=0.016) and lower left atrial dimensions (36 vs 41.5 mm, P=0.020) were observed in the group of cancer patients. As expected, patients with active cancer had significantly higher all-cause mortality during long-term follow-up (66.7 vs 29.4%, P=0.003). In a multivariable analysis of oncological MINOCA was independently associated with a long-term mortality (P<0.001).

Conclusions

To our knowledge, our study is the first report concerning a high prevalence of MINOCA in oncological patients with MI. We observed a significant proportion of cancer-associated anemia in this group of patients. The high incidence of takotsubo cardiomyopathy and significant differences in individual echocardiographic parameters underline the important role of cardiac imaging in this group of patients with unfavorable long-term prognosis.

Figure 1

Funding Acknowledgement

Type of funding source: None

Clot formation, lysis and ultrastructure in patients with acute phase myocardial infarction

Background/Introduction

Patients with established coronary artery disease have impaired clot structure and lysis. Prior research has compared patients with myocardial infarction to those with stable coronary artery disease (without a healthy reference), or patients after myocardial ischemia. The role of clot structure in the acute phase of the disease is unknown.

Purpose

Investigate clot structure in the acute phase of myocardial infarction (AMI) compared to healthy controls.

Methods

Plasma clots from AMI patients (within 12 hours of symptoms onset) or healthy controls were analyzed by turbidity and lysis. Clot pore size was determined by permeation. Clot ultrastructure was determined by confocal and scanning electron microscopy. Average fiber radius and protofibril packing were investigated by turbidimetry.

Results

Analysis on clot formation, using turbidity, showed increased lag time (24%, p<0.05), suggesting changes in protofibril packing and increased fiber size for AMI patients compared to controls. Additionally, AMI clots formed more quickly as evidenced by average rate of clotting (2.9-fold increase, p<0.001) and time to maximum absorbance (38% decrease, p<0.0001). Decreased plasminogen in AMI patients (23%, p<0.05) had strong effects on clot lysis, including increased time to half lysis (1.72-fold, p<0.0001) and increased time to maximum lysis rate (7.96-fold, p<0.0001). Taken together, these results suggest that AMI patients form less porous clots made from densely packed fibers with decreased numbers of protofibrils, which was confirmed using permeation (1.05-fold decrease, p<0.0001), confocal (Figure 1) and scanning electron microscopy (46% increase, p<0.0001), and turbidimetry (16% decrease, p<0.05) respectively.

Conclusions

Plasma from patients with AMI form denser and less permeable clots that lyse more slowly than healthy controls. These data show marked abnormalities in clot ultrastructure that contribute to the high risk of thrombosis during the acute phase of myocardial infarction, which has not shown in previous investigations.

Figure 1. Confocal microscopy of AMI vs. controls

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Jagiellonian University Medical College to G.G. (N41/DBS/000096) and BHF Programme Grant to S.R.B. and R.A.S.A. (RG/18/11/34036).

P1269 Relationship between left ventricle mass index and abdominal obesity in patients with metabolic syndrome hospitalized due to acute coronary syndrome

Background

There is evidence that metabolic syndrome (MS), as a cluster of acute coronary syndrome (ACS) risk factors, is associated with increased left ventricle mass index (LVMI). According to the 2009 IDF criteria of MS diagnosis, elevated waist circumference (≥94 cm in M, ≥80 cm in F), as a determinant of abdominal obesity (AO), is not an obligatory component of MS. Little is known about the relation of abdominal obesity to LVMI in pts with ACS.

Purpose

The aim of this study was to evaluate the relationship between abdominal obesity and LVMI, determined as LVM/H2,7, in patients with MS hospitalized due to ACS.

Methods

444 consecutive pts were enrolled based on ACS diagnosis. The pts were divided into two groups depending on MS diagnosis: group A – 310 pts with MS and AO (205 M, mean age 63.3 ± 10.5 yrs), group B - 134 pts without MS (101 M, mean age 61,4 ± 12.7 yrs). The group A was divided to two subgroups depending on AO diagnosis: group A1 - 288 pts with MS and AO (185 M, mean age 63.4 ± 10.2 yrs and group A2 - 22 pts with MS without AO (19 M, mean age 62,6 ± 12.7 yrs). In all enrolled pts hypertension was diagnosed.

Results

A significant difference was found between group A and B with the respect to LVMI (68.4 ± 25.9 vs. 58.3 ± 16.5, p < 0.05). In the group B, a significant association was found between LVMI and waist circumference (r = 0.39, p < 0.05), weight (r = 0.22, p = 0.012), as well as BMI (r = 0.35, p < 0.05). In group A, LVMI was significantly correlated only with weight (r = 0.24, p < 0.05). No significant differences were found between pts with AO and without AO with respect to LVMI (68.9 ± 26.2 vs. 61.4 ± 20.9, p = 0.187).

Conclusion

1. In individuals without MS hospitalized due to acute coronary syndrome significant positive correlation was found between LVMI and waist circumference, weight as well as BMI. 2. There is significant difference between pts with MS and without MS with the respect to LVMI. 3. No significant differences were found in LVMI between pts with AO and without AO.

Vestibular disease in dogs: association between neurological examination, MRI lesion localisation and outcome

OBJECTIVES

To determine whether the neurological examination correctly distinguishes between central and peripheral vestibular lesions in dogs.

MATERIALS AND METHODS

Retrospective study on dogs with vestibular disease presenting to two referral clinics in Germany.

RESULTS

Ninety-three dogs were included; neurological examination suggested central vestibular disease in 62 and a peripheral lesion in 31. MRI diagnosis was central vestibular disease in 68 dogs and peripheral in 25. Of the 62 dogs with a lesion localisation diagnosed as central vestibular by neurological exam, 61 were correctly identified (98.4%). Twenty-four of the 31 dogs diagnosed with a peripheral lesion by neurological exam had a consistent lesion on MRI (77.4%).

CLINICAL SIGNIFICANCE

The neurological examination is efficient at identifying lesions in the central vestibular system but less so for peripheral lesions. Therefore it is prudent to recommend imaging in dogs that show signs of peripheral vestibular syndrome but do not rapidly respond to treatment.

Elevated serum osteoprotegerin is associated with decreased osteoclastic differentiation in stenotic aortic valves

Calcific aortic valve stenosis (CAVS) is an actively regulated process that involves mechanisms of bone development, including the receptor activator of nuclear factor κB, its ligand, and osteoprotegerin (RANK/RANKL/OPG) regulatory system. The aim of this study was to investigate whether the levels of circulating OPG and RANKL can be correlated with some histopathological features of the stenotic valves. Serum levels of osteoprotegerin (OPG) and soluble RANKL (sRANKL) were assessed in 27 patients with CAVS prior to valve replacement surgery and in 12 control subjects. The removed valves were examined macroscopically and microscopically. Valve sections were stained with hematoxylin and eosin for general morphology, with Oil Red O for lipids and immunostained with antibodies against markers visualizing osteoclastic cells (tartrate-resistant acid phosphatase, TRAP), macrophages (CD68) and blood vessels (CD34). Patients with CAVS had elevated levels of OPG as compared to the control group (p=0.005). Within the CAVS group, patients with osteoclastic TRAP-positive cells in their valves had significantly lower serum levels of OPG (p=0.009) and lipid content (p=0.03) than those without such cells. Moreover, osteogenic metaplasia was observed exclusively in the valves containing TRAP-positive cells. Results of this study suggest that the circulating OPG can influence the processes occurring in the calcifying valves by inhibiting osteoclastic differentiation of cells involved in calcification and by preventing osteogenic metaplasia.

How accurate is image-free computer navigation for hip resurfacing arthroplasty? An anatomical investigation

BACKGROUND

The existing studies concerning image-free navigated implantation of hip resurfacing arthroplasty are based on analysis of the accuracy of conventional biplane radiography. Studies have shown that these measurements in biplane radiography are imprecise and that precision is improved by use of three-dimensional (3D) computer tomography (CT) scans. To date, the accuracy of image-free navigation devices for hip resurfacing has not been investigated using CT scans, and anteversion accuracy has not been assessed at all. Furthermore, no study has tested the reliability of the navigation software concerning the automatically calculated implant position. The purpose of our study was to analyze the accuracy of varus-valgus and anteversion using an image-free hip resurfacing navigation device. The reliability of the software-calculated implant position was also determined.

METHODS

A total of 32 femoral hip resurfacing components were implanted on embalmed human femors using an image-free navigation device. In all, 16 prostheses were implanted with the proposed position generated by the navigation software; the 16 prostheses were inserted in an optimized valgus position. A 3D CT scan was undertaken before and after operation.

RESULTS

The difference between the measured and planned varus-valgus angle averaged 1 degrees (mean +/- SD: group I, 1 degrees +/- 2 degrees ; group II, 1 degrees +/- 1 degrees ). The mean +/- SD difference between femoral neck anteversion and anteversion of the implant was 4 degrees (group I, 4 degrees +/- 4 degrees ; group II, 4 degrees +/- 3 degrees ). The software-calculated implant position differed 7 degrees +/- 8 degrees from the measured neck-shaft angle. These measured accuracies did not differ significantly between the two groups.

CONCLUSIONS

Our study proved the high accuracy of the navigation device concerning the most important biomechanical factor: the varus-valgus angle. The software calculation of the proposed implant position has been shown to be inaccurate and needs improvement. Hence, manual adjustment of the implant position in the software-planning step is frequently required.

Is a valgus position of the femoral component in hip resurfacing protective against spontaneous fracture of the femoral neck?: a biomechanical study

The aim of our study was to investigate whether placing of the femoral component of a hip resurfacing in valgus protected against spontaneous fracture of the femoral neck. We performed a hip resurfacing in 20 pairs of embalmed femora. The femoral component was implanted at the natural neck-shaft angle in the left femur and with a 10 degrees valgus angle on the right. The bone mineral density of each femur was measured and CT was performed. Each femur was evaluated in a materials testing machine using increasing cyclical loads. In specimens with good bone quality, the 10 degrees valgus placement of the femoral component had a protective effect against fractures of the femoral neck. An adverse effect was detected in osteoporotic specimens. When resurfacing the hip a valgus position of the femoral component should be achieved in order to prevent fracture of the femoral neck. Patient selection remains absolutely imperative. In borderline cases, measurement of bone mineral density may be indicated.

Robotic gait training: toward more natural movements and optimal training algorithms

This paper overviews our recent efforts to develop robotic devices to help people relearn how to walk after spinal cord injury. Our efforts are focused on two goals. The first is to develop robotic devices that allow natural gait movements and good force control. We have developed a five degrees-of-freedom robot (PAM) that accommodates natural pelvic movement during walking. PAM uses pneumatic actuators and a nonlinear control algorithm to achieve good force control. We have also developed a novel leg robot, ARTHuR, which makes use of a linear motor to precisely apply forces to the leg during stepping. Our second goal is to develop optimal training algorithms for robotic gait training. Toward this goal, we have developed a small-scale robotic device that allows us to test locomotor training techniques in rodent models. We have also developed an instrumentation system that allows us to measure how experienced therapists manually assist limb movement. Finally, we are developing computational models of motor rehabilitation. These models suggest that assisting in stepping only as needed with a force-controlled robotic device may be an effective method for improving locomotor recovery.

[Evaluation of magnesium cation levels in serum of patients with mitral valve prolapse syndrome]

Magnesium deficiency has been suggested to be related to the mitral valve prolapse syndrome (MVPS). The aim of the present study was to analyse the concentration of magnesium in blood plasma of patients (pts) with MVPS. In the group of 80 subjects, including 50 pts with MVPS and 30 healthy people matched for age and gender, who comprised the control group (CG), concentration of magnesium in blood plasma was estimated. Magnesium levels were measured by atomic absorption spectrophotometry. Mean concentration of magnesium cation in plasma in pts with MVPS was 0.74 +/- 0.12 mmol/l (range 0.47-1.02 mmol/l). It was only 1.02% lower than in the CG (x = 0.76 +/- 0.07 mmol/l; range 0.67-0.97 mmol/l). However evaluation of the magnesium concentration in blood plasma did not prove magnesium deficiency in the mitral valve prolapse syndrome. Moreover the study revealed that histograms of magnesium concentration values in both investigated groups were divergent.

[Variability of heart auscultation in patients with mitral valve prolapse]

The aim of the study was to analyze the auscultatory findings and its variability in 84 patients (pts) with mitral valve prolapse syndrome (MVPS) who were examined in the different body positions. All the pts underwent the echocardiographical examination and in 32 subjects (38%) prolapse of the anterior mitral leaflet was found, in 40 pts (48%) prolapse of the posterior mitral leaflet and in 12 (14%) pts prolapse of the both mitral leaflets. The auscultation of the heart was done in the supine position, in the lying position on the left side and in the upright position of the patient's body. Characteristic for the mitral valve prolapse (MVP) auscultatory findings (midsystolic murmur, late-systolic murmur and/or mid-systolic "non ejection" click) were demonstrated by 43 pts (51%) in the supine position. During the auscultation in the lying position of the pts on the left side, the auscultatory findings were found in 57 pts (68%) while in the upright position in 64 pts with MVPS (76%). The study showed that the auscultatory findings in pts with MVPS were demonstrated more frequently in the lying position of the body on the left side or in the upright position compared with the supine position. Moreover we found that 20 pts with MVPS (24%) did not demonstrate the characteristic auscultatory findings of MVP.

[The clinical course of end stage heart disease in 152 patients qualified for heart transplantation in a four year observation]

The aim of the study was to analyse the clinical course of pts with end stage disease (ESD) in the period of four years. The study population consisted of 152 pts (132 males, 20 females) at the age of 17-66 years (mean = 48.8 year SD = 9.1) primarily qualified to the heart transplantation (HTX). We analysed the ethiology of cardiac failure, the NYHA class of circulation insufficiency, frequency of occurrence of cardiac arrhythmias and conduction system disturbances in 24-hour ecg monitoring, and the pharmacotherapy efficacy. An ischemic ethiology of cardiac failure we found in 102 pts, cardiomyopathy (idiopathic, hypertrophic or postinfectious) in 46 and unoperable valvular disease--in 4. Ten pts were in II NYHA class, 112 in III, and 30 in IV. Left ventricular ejection fraction (echo assessed) ranged from 11% to 40%(mean = 24.9%), LVEDd = 46-111 mm (mean = 80.9 mm), LVESd = 34-83.5 mm(mean = 63 mm). We found IVa class by Lown ventricular arrhythmias (in Holter monitoring) in 38 pts and IVb in 78. Fifty six pts were treated with amiodarone, 10--with beta-blockers and 11 with sotalol. 19 pts were treated by permanent cardiac pacing during the waiting period, 2 ones--by PTCA, 2--by CABG, three ones--by dynamic cardiomyoplasty, and one--by partial aneurysmectomy. One pt was treated by CABG and automatic cardioverter-defibrilator implantation. In 5 cases HTX was delayed because of the positive effect of pharmacotherapy. In assessed period HTX were performed in 64 cases, 31 pts died and 43 are still waiting for the procedure.

CONCLUSIONS

During the 4-year period HTX were performed in 42% of waiting pts. Mortality in this group was 38.2%. In 9 pts (5.9%) the alternative methods of surgical treatment were applicable. In 5 pts (3.9) the decision about HTX was delayed because of the positive change of the clinical status. This fact confirms the necessity of the waiting list verification.

[Present day opinion about beta block treatment of congestive heart failure]

The congestive heart failure is an important clinical problem because of its frequency of appearance and poor prognosis. A new groups of drugs are to be found to change the negative natural course of this disease. Beta adrenolytic agents are on focus now because of promising results of small and great clinical trials and wider knowledge about the pathophysiology of congestive heart failure. This paper presents the present day knowledge about the role of the beta blockers therapy in the congestive heart failure treatment.

Successful full-term pregnancy in a patient three and a half years after a heart transplant

The patient is a 28 year old woman who received a heart transplant in 1992 secondary to hypertrophic cardiomyopathy with unremarkable post-operative course. In the period immediately post transplantation the patient was on a four-drug immunosuppressive regimen which was subsequently changed to standard three-agent therapy. This therapy was continued until the patient became pregnant. In the first trimester only Cyclosporine (CsA) was used, and thereafter, the patient was continued on the previous three agent regimen. Toward the end of pregnancy a rise in systolic pressure was observed, but the child was delivered by spontaneous vaginal delivery without complications in the 38th week of pregnancy. The newborn weighed 3320 g and was in good health. A sharp fall in the newborn CsA blood levels was observed post delivery reaching zero level on the third day of life. At the present time, both mother and baby are in good health, 6 weeks after delivery.